a new administration and new opportunities for medical ......medical education @atulgrovermd. agenda...
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Atul Grover, MD PhDExecutive Vice PresidentMarch 30, 2017
AIAMC Annual MeetingAmelia Island, FL
A New Administration and New Opportunities for Medical Education
@AtulGroverMD
Agenda
• Burning Issues Inside the Beltway• Current Opportunities in
Medical Education Clinical Care Healthcare Research
© 2015 AAMC. May not be reproduced without permission.
Great Challenges: • Divided Political Environment, • Extraordinary Policy Debate
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Patient Care For All
Training
Research
Stand-by Capacity
And All AMC Missions Rely on Special Gov’t. Payments: Cut Them, Cut Missions
Clinical
AMCIME
DSH
NIH
© 2015 AAMC. May not be reproduced without permission.
To Underscore the Obvious, AMC Financial Viability Could be Seriously Affected by:• Change in # of Uninsured
Affects Charity Care
• Change in Medicaid Policy Affects DSH, Uncompen-sated Care, Uninsured
All Policies Are in Play in New
Admini-stration, New
Congress
• Change in Medicare Policy Affects GME,
Quality Measures
• Changes in NIH, AHRQ, PCORI Affect
Research
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President Obama
186
46**
246
54
President Trump
241
48** 52
3 194
1 Party Now Leads House, Senate, and White House: Complex Picture
*
2016 2017
House
Senate
Source: https://en.wikipedia.org/wiki/United_States_House_of_Representatives_elections,_2016 *Vacancies ** VT. ME Senators = Indep., vote with Ds
Two Key Points about Complexity:• Takes 60 Senate votes, not 51, to pass bills – except
for “budget reconciliation” = only 51
• 54% of House, 37% of Senate NOT in Congress in 2010
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Before Election, President Trump’s Health Agenda: Succinct, Few Details
Candidate, Campaign Web Page Advocated:
Source: https://www.greatagain.gov/policy/healthcare.html
• Repeal ACA, Replace with:Interstate insurance sales, HSAs, High risk pools...
After Election, Transition Web Site Highlighted: in Addition to ACA Repeal:• Advance research – more for NIH?
• Modernize Medicare – premium support?
• Maximize states’ flexibility – cap Medicaid $
• Reform FDA – faster approval, lower price
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Since Jan. 1, President Trump Still Succinct, But Not Always ConsistentBefore Inauguration Day:• Move Fast, Has ACA Repeal Plan• Do Repeal & Replace Soon and
Together, Not Separately
On Inauguration Day: • First Executive Order Is on ACA – but Vague
Since Inauguration Day:• Talks about Medicaid Block Grants• Talks about Taking Longer for ACA Repeal – 2018• Confirmed, HHS Sec. Price Likely to Achieve Focus
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AAMC Advocacy on ACAAAMC CEO Darrell G. Kirch’s Letter to President- Elect Trump:“…(T)o repeal the ACA without simultaneously enacting accompany-ing legislation specifically guarantee-ing similar coverage (to the ACA) would jeopardize the nation’s health care system…there cannot be repeal without replace.”
“Congress should protect states, tax payers, and Medicaid beneficiaries by not repealing the Medicaid expansion” (made possible by the ACA).
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With all of this uncertainty, how can we create opportunity?
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New Administration and 115th Congress:We’re Emphasizing Academic Medicine’s Principles, Expertise, Positions, Contacts
AAMC Transition Binder
AAMC Principles
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Academic Medicine: Disproportionate Provider of Patient Care, Research, Training
Source: Table G5, Inpatient and Outpatient Operations Data Fiscal Year 2012 Data, AAMC Data Book, April 2014
of all U.S. hospitals are COTH hospitals
5%Teaching hospitals & medical schools receive :
of all residentsof NIH Extramural Research Awards
50+% 74%
These teaching hospitals provide critical services often not available elsewhere. Teaching hospitals operate:
23% of all hospital care
20% of all Medicare In-patient days
24% of all Medicaid in-patient days
37% of charity care
AAMC hospitals provide training to:
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Medical Education
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Embrace competency-based education for our trainees
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Premedical MedicalSchool
Residency and Fellowships
Practice
Learning
Assessment
Facts
…We Are Rethinking Medical Education
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Premedical MedicalSchool
Residency and Fellowships
Practice
Learning
Assessment
Competencies
…We Are Rethinking Medical Education
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Patient Care
Knowledge for Practice
Personal and Professional DevelopmentSystems-based
Practices
Practice-based earning and improvement
Professionalism
Interpersonal and Communication Skills
The Health Care Provider
Inter-professional Collaboration
Accelerating the Shift to Competency-Based Education
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a set of activities that entering residents should be expected (entrusted) to perform on day oneof residency without direct supervision.
1) Gather a history and perform a physical examination
2) Prioritize a differential diagnosis following a clinical encounter
3) Recommend and interpret common diagnostic and screening tests
4) Enter and discuss orders/prescriptions5) Document a clinical counter in the
patient record6) Provide an oral presentation of a
clinical encounter7) Form clinical questions and retrieve
evidence to advance patient care
8) Give or receive a patient handover to transition care responsibility
9) Collaborate as a member of an interprofessional team
10) Recognize a patient requiring urgent or emergent care, and initiate evaluation and management
11) Obtain informed consent for tests and/or procedures
12) Perform general procedures of a physician
13) Identify system failures and contribute to a culture of safety and improvement
Core Entrustable Professional Activities
www.aamc.org/cepaer
© 2014 AAMC. May not be reproduced without permission.
Four competencies with 38 sub-competencies:
Values and ethics
Roles and responsibilities
Interprofessional communications
Teams and teamwork
Core Competencies for Interprofessional Collaborative Practice
© 2014 AAMC. May not be reproduced without permission.
Ensure a positive learning environment
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NAM Action Collaborative on Clinician Well-Being and Resilience
physicians commit suicide each year, a rate more than
400
that of the general population
2X
-Andrew & Brenner, 2015
23-31%Prevalence of emotional exhaustion among primary nursesGarnez-Urquiza et al, 2016
Learn more at nam.edu/ClinicianWellBeing
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Improving the Learning Environment
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Clinical Care
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Significant Changes in the Health System…
Tomorrow
Paper Records
Independent Hospitals and Physician Offices
Fee For Service
Electronic Health Records
Value-Based and Bundled Payments
Large Health Systems with Employed Physicians
Yesterday
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0%
5%
10%
15%
20%
25%
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
Rev
enue
at R
isk
(Milli
ons)
Fiscal YearClinical Revenue At Risk
Medicare Revenue at Risk for Major Teaching Hospitals
Source: AAMC Analysis Medicare Final Rule IPPS Impact File, September 2015. Analysis excludes hospitals from Maryland and Puerto Rico.
© 2015 AAMC. May not be reproduced without permission.
Average Operating Margin of Participating Hospitals, FY2006-FY2015
-3%-2%-1%0%1%2%3%4%5%6%7%8%9%
10%11%12%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Ope
ratin
g M
argi
n
Operating Margin 25th Percentile Average of Independent RespondentsAverage of All Respondents Average of Integrated Respondents
Note: The number of participating hospitals varies by year. All hospitals with missing values are excluded. In some years, the average of all respondents correctly appears close to the 25th percentile of all respondents due to skewed data.
Source: COTH Annual Survey of Hospital Operations and Financial Performance, FY2006-FY2015
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A Spectrum of New Possibilities
Management Agreement
Service Line Affiliation
Enterprise Joint
Venture
Joint Operating Agreement
Merger/Affiliation
Asset Acquisition
Level of IntegrationCapital Commitment
Change in Governance/Control
Why Collaborate?
More Coordinated
Right site of service
Geographic coverage, cover access gaps
Build education/training pipeline
Expand research, care advances
Reduce inappropriate variation
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“There is no single right answer to determining the ideal size for fulfilling an institution’s mission for health professional education. However, one clearly wrong answer is to fail to address this question”
The Blue Ridge Academic Health Group, Winter 2016
Source: The Blue Ridge Academic Health Group, Winter 2016, Report 20 http://whsc.emory.edu/blueridge/publications/archive/Blue%20Ridge-2016.pdf
Be bold in forging care models that meet patients’ needs
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Advancing New Practice Models
Project CORECoordinating Optimal Referral Experiences
Bundled Payments for Care Initiative including workshops
Price Transparency in Teaching Hospitalsresources and case studies
Advisory Panel on Health Care examining Mergers and Acquisitions
Future of the Academic Health System Roundtablewith consulting firms
Pilot Programs
Expert Analysis
Resources and Tools
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Referrals to Subspecialty Medical Services are Rising Rapidly
1 in 3 patients are referred to a
specialist each year
Source: Barnett, Song and Landon. Trends in Physician Referrals in the United States, 1999-2009. Archives of Internal Medicine, 2012.
1 in 2 Medicare patients are referred to a
specialist each year
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Poor access to specialty care for
patients
Poor communication & coordination
between PCPs & specialist colleagues
Wide variations in care
Current Challenges at the Interface of Primary Care & Specialty Care
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The CORE Model: Implementing Enhanced Referrals & eConsults in the EMR
© 2015 AAMC. May not be reproduced without permission.
106
397
677
998
1156
1392
1695
1849
0
200
400
600
800
1000
1200
1400
1600
1800
2000
9/14-11/14 12/14-2/15 3/15-5/15 6/15-8/15 9/15-11/15 12/15-2/16 3/16-5/16 6/16-8/16
Total eConsults Completed by QuarterSept 2014 - Aug 2016
>8,000 eConsults completed across sites in Years 1 & 2
Wave 4 Launch
Wave 1 Launch
>8,000 eConsults Completed in the first 18 Months at the 5 pilot AMCs
(with successive waves of specialties going live over ~15 months)
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Impact of the first 8,000 econsultsat the 5 Pilot AMCs
46%would have sent a
referral
~3,600avoided referrals
40%would have curbsided
the specialist
~3,200avoided curbsides
Improves access, reduce referral leakage, allows
for higher acuity referrals
Specialists receive RVU credit for
consultation, which is documented in the EMR
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Committed to further scaling this innovation & improving the quality of ambulatory
care, the AAMC is working to:
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Healthcare Research
© 2015 AAMC. May not be reproduced without permission.
AAMC HHS Priorities FY 2017 Funding
Programs FY 2016 Enacted
FY 2017 SenateComm.
FY 2017 HouseComm.
AAMC FY17 Recommendation
National Institutes of Health $32.1 billion $34.1 billion $33.3 billion $34.1 billion
Title VII Health Professions $262.4 million $297.3 million $294.2 million $262.4 million
Title VIII Nursing $229.4 million $229.4 million $229.4 million $229.4 million
National Health Service Corps (NHSC) (not appropriated) $310 million
$0 (NHSC is mandatory
funding)
$0 (NHSC is mandatory
funding)N/A
Children’s Hospitals Graduate Medical Education Payment Program (CHGME)
$295 million $300 million $300 million $300 million
Agency for Healthcare Research and Quality (AHRQ) $334 million $324 million $280 million $334 million
Centers for Disease Control and Prevention (CDC) $7.23 billion $7.12 billion $7.84 billion N/A
Encourage Innovation Beyond The Bench
Comparative clinical effectiveness
research
Community and population research
Health professions education research
Health care delivery researchImplementation and
Dissemination Research
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AAMC Applauds 21st Century Cures Act
FY 2017 Funding: AAMC Urges Completingthe Move to Boost NIH by $2 Billion
260 patient, medical, scientific, academic, and research groups signed letter coordinated by the Ad Hoc Group for Medical Research
to President Trump and Congressional leadership, urging the completion of an FY 2017 spending package that includes $2 billion increase for NIH.
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Demonstrating the Power of Research
medresearch.tumblr.com
Share These Resources with Your Colleagues
Foster resilience in ourselves and those around us
[Resilience is] the glue that holds groups together, provides a purpose larger than the solitary self, and allows entire groups to rise in challenges.
Martin Seligman, Ph.D. Flourish
We Are More Resilient Than We Realize
“”
Leadership is not a special gift or power held by a select few. Instead, it is a relationship established among committed people.
Darrell G. Kirch, MDAAMC President and CEO
“”
AAMC Advocates For Sustainable Support For Academic Medicine!